Revealing hidden hunger


Childhood hunger brings to mind swollen bellies and wide eyes from other parts of the world. These images are why food insecurity in the US can go unnoticed.

The concept of childhood hunger often conjures an infomercial-generated, stereotyped vision of swollen bellies and wide, pleading eyes from a remote corner of the world. This is an image to which most Americans find it difficult to relate, let alone accept, as a condition quietly plaguing children within our own communities. Perhaps this misconception is why food insecurity, defined as the lack of access to enough food to fully meet basic nutritional needs at all times because of lack of resources (Table 1),1-4 can so easily and often go unrecognized in the United States. The striking reality is that more than 1 in 5 American households with children is food insecure.5


Risk factors and demographics

There is a common association between hunger and poverty, and in households with children, unemployment and low wages are important predictors of those families at risk for food insecurity.2,6 However, it is important to note that food insecurity is not at all exclusive to impoverished families. One in 5 households with food insecure children have annual incomes well above the poverty line. Families living in this category may not qualify for other assistance programs, further exacerbating the problem of inadequate access to food.

Although more prevalent in urban and rural communities, food insecurity also affects children living in the suburbs.6 Suburban unemployment (and poverty) is a growing problem, and the rising number of unemployed suburban families is likely accompanied by increasing rates of food insecurity.7 Hunger in suburbia is often overlooked, but recent data has emphasized that suburban food insecurity is present and growing.

In 2010, 6.2 million suburban households were classified as food insecure, and an additional 2.3 million households demonstrated very low food security.8 Another study estimates that nearly half of clients served by food banks live in rural or suburban areas.9 Although patterns suggest that the southern and western regions of the United States are disproportionately affected (paralleling the disproportionate poverty in those regions), no region remains unaffected.10-13

Despite some progress in reducing food insecurity on the national level, in some places food insecurity is growing. For example, in Ohio, 18.1% of families met criteria for food insecurity in 2010, an increase from 17.1% in 2009.11

One effort to combat our nation’s problem of food insecurity is the federal Supplemental Nutrition Assistance Program (SNAP), formerly known as the Food Stamp Program. Data from 2010 reveal that approximately 75% of the 51 million persons eligible for SNAP received benefits.14

Suburban enrollment in SNAP is accelerating compared with enrollment of urban participants, such that participation is higher in rural compared with urban households (86% vs 73%).14,15 Children comprise a relatively high proportion of those receiving benefits, with an estimated 88% of eligible children receiving benefits through SNAP. Enrollment in federal food and nutrition assistance programs such as SNAP is a risk factor for food insecurity.6 Rates of food insecurity are higher among persons receiving benefits compared with qualified persons not receiving benefits, suggesting that perhaps nonparticipating qualified persons are able to meet their nutritional needs without federal assistance.

Children at risk

Food insecurity is of particular relevance to the field of pediatrics for several reasons. First, households with children are at increased risk for food insecurity compared with households without children such that up to 20% of households with children are food insecure.2,16,17 Furthermore, single-parent households are at a higher risk of suffering from food insecurity compared with 2-parent households (households with single mothers, 35.1%; single fathers, 25.4%; 2-parent households, 13.8%).2,8 The bottom line is staggering: Food insecurity affects more than 16 million children in the United States.11 Thus, regardless of practice setting and location, all practicing pediatricians are seeing children living in food insecure households, but are we recognizing them? Employing a simple screening process enables the pediatrician to identify children who lack basic necessities including access to an adequate supply of nutritious food. Identifying and addressing such deficits make us better suited to meet our patients’ most critical needs.

Aspects of food insecurity

Families who are food insecure often worry about running out of food before they can afford to buy more. Such families are typically unable to afford balanced meals and may cut the size of meals or skip meals because there was not enough money for food. They report feeling hungry but did not eat because they could not afford enough food. Some people lose weight because of lack of money or may experience days when they eat nothing because they cannot afford to buy food.2,3,8 In contrast, there is evidence that some food-insecure people may be at increased risk for being overweight or obese because of the increased intake of low-cost, high-calorie, energy-dense foods.17-23

Food insecurity can often be invisible. Despite occurring in all ages, ethnicities, and neighborhoods, the frequent lack of telltale signs on physical exam makes it especially difficult to identify and subsequently address. As a result, unrecognized food insecurity leads to a child’s basic needs remaining unmet, potentially threatening the health of our nation’s affected children and the stability of their families.

Abraham Maslow in 1943 developed a well-accepted model of the hierarchy of basic human needs.19 The foundation of this model involves physiologic requirements: shelter, warmth, and food. Suppose each of these components is at the base of Maslow’s model as 1 leg of a 3-legged stool on which the upper tiers of the hierarchy rest (Figure). If one of those basic needs is threatened or unobtainable, the stool wobbles, then collapses, leading to destruction of the entire structure.

In this model, food insecurity may be likened to a shortened leg, creating a wobbly stool. With an unstable foundation, addressing higher-level aspects of pediatric health needs such as growth and development or providing anticipatory guidance becomes a lower priority.

Consequences of food insecurity

There is a common misconception that persons who are food insecure will be underweight because of insufficient caloric intake; however, most food-insecure children have normal growth parameters.

Multiple studies have linked food insecurity as an underlying factor of excess weight gain in children,17,20-22 although the strength of such an association remains controversial.4,17,20-29 Many factors likely contribute to this phenomenon, such as the predominance of low-quality, high-calorie foods in their diets. Behavioral factors also play a role. For example, food-insecure persons may resort to binge eating when food is available because their food insecurity may lead them to question the time and place of the next available meal.22,30-32

Although research on adverse childhood experience is an emerging field, and causation cannot be proved, strong associations are evident. Children from food-insecure families may suffer medical consequences.33-37 The micronutrient deficiencies associated with food insecurity can contribute to anemia, developmental delay, acute illnesses, increased hospitalizations, and poor health outcomes.1,4,26,37,38 School-aged children also have been noted to have negative associations at school, such as lower math achievement scores, higher likelihood of repeating a grade, and increased risk of suspension.25,39 Additionally, these children can be at higher risk of emotional and behavioral problems.40-42

Families facing food insecurity can also struggle with other social and financial hardships. Budgetary trade-offs can force families to prioritize among basic needs of food, rent, utilities, transportation, and medical care. Researchers have documented the “heat or eat phenomena,” in which children from poor families eat almost 11% fewer calories during the winter when utility bills are higher. This difference was not observed in children from wealthier families.33

Screening for food insecurity

The most difficult part of identifying and addressing food insecurity often lies within the details associated with screening. Who performs the screening, and who pays for it? If you identify an issue, can you address it? Are appropriate resources readily available to effectively and immediately aid those persons identified as food insecure? Further, how does one provide appropriate interventions or follow-up?

Encouraging and implementing a standardized screening process in routine well-child care is 1 potential option for reliably incorporating food insecurity assessment. The US Department of Agriculture (USDA) has developed several food-insecurity screening tools, available on its Web site. The primary care centers at Cincinnati Children’s Hospital Medical Center (CCHMC), for example, use a simplified 2-question version of the evidence-based, 6-question USDA screening tool (Table 2).3,16,34

These questions were validated, and a positive response to either question has a sensitivity of 97% and specificity of 83% for identifying a food-insecure household.16 This food-insecurity screening tool is incorporated into the electronic medical record and performed by the examining physician during the nutrition-screening portion of every well-child visit at CCHMC primary care centers.

Incorporating screening into your daily clinical practice

Before formally initiating a standardized screening tool in your practice, it is prudent to supply providers and staff with a current list of local and national resources that address food insecurity and provide emergency assistance to those patients identified as food insecure.

To accomplish this in primary care sites, it is helpful to reach out to several community agencies to better understand community resources and establish relationships to simplify the referral and information-sharing process for families. Medical-legal partnerships can be created, combining the expertise of physicians, attorneys, and social workers to best advocate for families with public benefit issues. Collaborations with community partners, including local food banks and the local early intervention program, can provide additional and invaluable avenues for referral.

Many providers and offices lack on-site social workers or legal advocates. In these situations, an up-to-date, relevant, and easily accessible resource list available for medical providers to share with families in need is critical. Such a list could include Women, Infants, and Children (WIC) locations, contact information for the local public benefits agency, and community food pantries. Regardless of available on-site resources, an interdisciplinary approach that takes advantage of clinic- and community-based strengths facilitates screening and referral to appropriate resources to promote food security (Table 3).

Overcoming barriers to screening

There are 2 major barriers to incorporating screening for food insecurity into routine well-child care: time and reimbursement. The 2-question screening model takes very little time because it is easily incorporated into the nutrition-screening portion of the well-child visit, and if negative, requires no more than a few seconds to complete. If screening yields a positive result, addressing newly identified food insecurity may be time consuming but would arguably be 1 of the most important problems to address at that visit.

The question of reimbursement is not as simply resolved. At this time, screening for food insecurity is not a reimbursable charge. In the recent health care discussions, the importance of preventive care has been newly emphasized. Ensuring that all children have adequate access to nutritious food is 1 of the most important preventive measures we can take as stewards of child health and as advocates for change in our current and future health care system.

Opportunities for help

Overall, SNAP has been shown to be effective in reducing very low food insecurity by estimates of 20% to 50%. However, the program is rarely sufficient to meet all needs of the food insecure.43 Additional programs, some geared specifically for children (ie, school breakfast, lunch, and snack programs and summer nutrition programs), exist at federal, state, and local levels to attempt to bridge this gap. Details about eligibility for and access to such programs are available on the USDA Web site and others (Table 3).

The painful reality of hunger in our country is that it is pervasive yet often invisible. As physicians, we have a responsibility to ask the families we serve about their access to food and to be prepared with resources and assistance for those who disclose food insecurity. Some providers may hesitate to ask certain families who seem to be at low risk about food insecurity, concerned that such questions could be embarrassing or even offensive. However, the data illustrate that food insecurity is not limited to any single demographic and is exceptionally difficult to identify if not directly discussed.

Regardless of our specialty, expertise, or practice location, allowing our patients’ most basic needs to go unmet by simply failing to ask questions makes the art of managing complex disease seem comparatively trivial. Although we can rarely resolve such complicated situations on our own, providing an avenue for disclosure and an opportunity to provide resources can be the first steps in changing the outcome for children and their families.


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2. Nord M, Andrews M, Carlson S. Household Food Security in the United States, 2008. ERR-83, US Department of Agriculture, Economic Research Report. 2009.

3. Bickel G, Nord M, Price C, Hamilton W, Cook J. Guide to Measuring Household Food Security. Revised 2000. Alexandria, VA: US Department of Agriculture, Food and Nutrition Service; 2000.

4. Cook JT, Frank DA, Berkowitz C, et al. Food insecurity is associated with adverse health outcomes among human infants and toddlers. J Nutr. 2004;134(6):1432-1438.

5. Rose-Jacobs R, Black MM, Casey PH, et al. Household food insecurity: associations with at-risk infant and toddler development. Pediatrics. 2008;121(1):65-72.

6. Nord M. Food Insecurity in Households with Children: Prevalence, Severity, and Household Characteristics. EIB-56. US Department of Agriculture, Economic Research Service. 2009. 

7. Tavernise S. Outside Cleveland, snapshots of poverty’s surge in the suburbs. New York Times. October 24, 2011.

8. Coleman-Jensen A, Nord M, Andrews M, Carlson S. Household Food Security in the United States in 2010. ERR-125. US Department of Agriculture, Economic Research Report. 2011.

9. Mabli J, Cohen R, Potter F, Zhao Z; Mathematica Policy Research. Hunger in America 2010. National Report Prepared for Feeding America. Final Report. Chicago, IL: Feeding America; 2010.

10. Berube A, Frey WH; Brookings Institution Center on Urban and Metropolitan Policy. A Decade of Mixed Blessings: Urban and Suburban Poverty in Census 2000. Washington, DC: Brookings Institution; 2000.

11.Map the Meal Gap, Food Insecurity in Your County. Feeding America Web site. Updated May 25, 2012. Accessed January 3, 2013.

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13. DeNavas-Walt C, Proctor BD, Smith JC; US Census Bureau. Income, Poverty, and Health Insurance Coverage in the United States: 2007. Washington, DC: US Government Printing Office; 2008.

14. Eslami E, Leftin J, Strayer M; Mathematica Policy Research. Supplemental Nutrition Assistance Program Participation Rates: Fiscal Year 2010.  Alexandria, VA: US Department of Agriculture, Food and Nutrition Service; 2012.

15. Garr E; Brookings Institution Metropolitan Policy Program. The Landscape of Recession: Unemployment and Safety Net Services Across Urban and Suburban America. Washington, DC: Brookings Institution; 2011.

16. Hager ER, Quigg AM, Black MM, et al. Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics. 2010;126(1):e26-e32.

17. Casey PH, Simpson PM, Gossett JM, et al. The association of child and household food insecurity with childhood overweight status. Pediatrics. 2006;118(5):e1406-e1413.

18. Nord M. Measuring US Household Food Security. Amber Waves. 2005. Accessed January 3, 2013

19. Maslow AH. A theory of human motivation. Psychol Rev. 1943;50(4):370-396.

20. Rose D, Bodor JN. Household food insecurity and overweight status in young school children: results from the Early Childhood Longitudinal Study. Pediatrics. 2006;117(2):464-473.

21. Matheson DM, Varady J, Varady A, Killen JD. Household food security and nutritional status of Hispanic children in the fifth grade. Am J Clin Nutr. 2002;76(1):210-217.

22. Dubois L, Farmer A, Girard M, Porcherie M. Family food insufficiency is related to overweight among preschoolers. Soc Sci Med. 2006;63(6):1503-1516.

23. Metallinos-Katsaras E, Sherry B, Kallio J. Food insecurity is associated with overweight in children younger than 5 years of age. J Am Diet Assoc. 2009;109(10):1790-1794.

24. Cook JT, Frank DA. Food security, poverty, and human development in the United States. Ann N Y Acad Sci. 2008;1136:193-209.

25. Jyoti DF, Frongillo EA, Jones SJ. Food insecurity affects school children’s academic performance, weight gain, and social skills. J Nutr. 2005;135(12):2831-2839.

26. Black MM, Cutts DB, Frank DA, et al; Children’s Sentinel Nutritional Assessment Program Study Group. Special Supplemental Nutrition Program for Women, Infants, and Children participation and infants’ growth and health: a multisite surveillance study. Pediatrics. 2004;114(1):169-176.

27. Chamberlin LA, Sherman SN, Jain A, Powers SW, Whitaker RC. The challenge of preventing and treating obesity in low-income, preschool children: perceptions of WIC health care professionals. Arch Pediatr Adolesc Med. 2002;156(7):662-668.

28. Young-Hyman D, Herman LJ, Scott DL, Schlundt DG. Care giver perception of children’s obesity-related health risk: a study of African American families. Obes Res. 2000;8(3):241-248.

29. Wood DL, Valdez RB, Hayashi T, Shen A. Health of homeless children and housed, poor children. Pediatrics. 1990;86(6):858-866.

30. Kendall A, Olson CM, Frongillo EA Jr. Relationship of hunger and food insecurity to food availability and consumption. J Am Diet Assoc. 1996;96(10):1019-1024; quiz 1025-1026.

31. Townsend MS, Peerson J, Love B, Achterberg C, Murphy SP. Food insecurity is positively related to overweight in women. J Nutr. 2001;131(6):1738-1745.

32. Fisher JO, Birch LL. Restricting access to foods and children’s eating. Appetite. 1999;32(3):405-419.

33. Bhattacharya J, DeLeire T, Haider S, Currie J. Heat or eat? Cold-weather shocks and nutrition in poor American families. Am J Public Health. 2003;93(7):1149-1154.

34. Connell CL, Nord M, Lofton KL, Yadrick K. Food security of older children can be assessed using a standardized survey instrument. J Nutr. 2004;134(10):2566-2572.

35. Frank DA, Neault NB, Skalicky A, et al. Heat or eat: the Low Income Home Energy Assistance Program and nutritional and health risks among children less than 3 years of age. Pediatrics. 2006;118(5):e1293-e1302.

36. Garg A, Butz AM, Dworkin PH, Lewis RA, Serwint JR. Screening for basic social needs at a medical home for low-income children. Clin Pediatr (Phila). 2009;48(1):32-36.

37. Ma CT, Gee L, Kushel MB. Associations between housing instability and food insecurity with health care access in low-income children. Ambul Pediatr. 2008;8(1):50-57.

38. Krugman SD, Dubowitz H. Failure to thrive. Am Fam Physician. 2003;68(5):879-884.

39. Winicki J, Jemison K. Food insecurity and hunger in the kindergarten classroom: its effect on learning and growth. Contemp Econ Policy. 2003;21(2):145-157.

40. Kleinman RE, Murphy JM, Little M, et al. Hunger in children in the United States: potential behavioral and emotional correlates. Pediatrics. 1998;101(1):E3.

41. Weinreb L, Wehler C, Perloff J, et al. Hunger: its impact on children’s health and mental health. Pediatrics. 2002;110(4):e41.

42. Whitaker RC, Phillips SM, Orzol SM. Food insecurity and the risks of depression and anxiety in mothers and behavior problems in their preschool-aged children. Pediatrics. 2006;118(3):e859-e868.

43. Nord M. How much does the Supplemental Nutrition Assistance Program alleviate food insecurity? Evidence from recent programme leavers. Public Health Nutr. 2012;15(5):811-817.

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